Would you start a short-acting beta agonist (SABA) in a patient with a resolved fever and persistent cough from an upper respiratory infection, but no shortness of breath or wheezing?

Short-Acting Beta Agonist for Upper Respiratory Infection with Persistent Cough

Do not start a short-acting beta agonist (SABA) in this patient. This is an otherwise healthy patient with an uncomplicated upper respiratory infection, resolved fever, clear lungs, no wheezing, and no shortness of breath—there is no indication for bronchodilator therapy.

Clinical Reasoning

When SABAs Are NOT Indicated

• In acute bronchitis without wheezing, β2-agonist bronchodilators should not be routinely used to alleviate cough 1
• The American College of Chest Physicians specifically recommends against routine SABA use in most patients with acute bronchitis (Grade D recommendation) 1
• Your patient has clear lungs with no wheezing—this is the critical distinguishing feature that argues against SABA use

The Exception: When to Consider a SABA Trial

• Only in select adult patients with acute bronchitis AND wheezing accompanying the cough should treatment with β2-agonist bronchodilators be considered useful 1
• This represents a small subset where there is evidence of bronchospasm (wheezing on exam or patient-reported wheeze with dyspnea)

Why This Matters

Potential Harms Without Benefit

• SABAs can cause paradoxical bronchoconstriction in patients without underlying bronchospasm, particularly in those with airway hyperresponsiveness 2
• Common adverse effects include tachycardia, tremors, palpitations, and headache—all without therapeutic benefit in the absence of bronchospasm 1, 3
• A small proportion of patients may experience increased airway resistance after SABA administration 1

The Evidence Base

• Short-acting β-agonists are indicated for controlling bronchospasm and relieving dyspnea—neither of which your patient has 1
• The primary role of SABAs is for rapid reversal of airflow obstruction in conditions like asthma exacerbations or acute exacerbations of chronic bronchitis with bronchospasm 1
• In stable chronic bronchitis, SABAs may reduce chronic cough in some patients, but this is in the context of underlying chronic airway disease, not acute viral URI 1

Common Pitfall to Avoid

Do not prescribe SABAs simply because a patient has a cough. The presence of cough alone, even if persistent, does not justify bronchodilator therapy. The key clinical indicators for SABA use are:

• Wheezing on examination 1
• Shortness of breath with evidence of bronchospasm 1
• Known reactive airway disease or asthma 1

Your patient has none of these features.

What to Do Instead

For symptomatic relief of cough in acute bronchitis without wheezing:

• Antitussive agents (such as dextromethorphan or codeine) can be offered for short-term symptomatic relief, though evidence is limited (Grade C recommendation) 1
• Reassurance that viral URI symptoms typically resolve within 2-3 weeks
• Return precautions if wheezing or shortness of breath develops

If wheezing develops later, then reassess and consider a trial of SABA at that time 1.